TMJsurgeon.com TMJ pathology and associated headache…Part II: A post surgical evaluation of chronic headache response to surgical treatment.

The International Headache Society sites TM joint disorder/pathology as a viable cause of headache (Section 11.7 of Guidelines/Classification of Headache…www. i-h-s.org…{see guidelines/classifications}.  The previous blog was to provide the “academic” argument for viable consideration of significant TM joint pathology and associated headache.

There are very few articles in the Oral/maxillofacial surgical literature that have looked specifically at headache response after TM joint surgery.  I would appreciate anyone forwarding me references to the contrary to put in my reference library.  The following is an excerpt of a paper published in the North Carolina Medical Journal that I wrote in 1993 that looked specifically at headache response to treatment for significant derangement/arthrosis of the TM joint.  The results of those days are comparable to what is happening today….only I think the percentages of patients with no significant improvement is less…because the surgical methods are better now than at that time.  Regardless, here are the results.

METHODS

Questionaires were sent to 83 consecutive patients who had undergone surgery ( of the joint itself, no other jaw surgery)  during a three year period between 1986 to 1988.  76 were returned for a response rate of 91.6% (unusually high with patient populations and a study of this sort…ed. comment)  All patients had intrinsic disease of the TM joint(S) documented by MRI.  A non surgical treatments had failed (physical therapy, occlusion (bite) management, splint appliances, anagesics, anti-inflammatory medications, joint injections (arthrocentesis/steroids), and even specific medications prescribed for headache that was thought to be migraine or vascular headace.  All patients had negative neurologic evaluation pre operatively or these issues ruled out by their primary physician or neurologis pre operatively.  The questionnaire asked about the patient’s present headache status compared to that of the pre operative state. Specifics of a numerical pain/headache severity scale (visual analog scale data) and a subjective duration of present headache were evaluated.

Four categories were used to determine frewquency of pain: 1, constant;  2) 1-3 times per week; 3) one time per month; 4)  no headache pain.

Patients were asked to locate headache both in the the pre operative state and the post operative state.  The following regions were used as locales: frontal, temporal, retro-orbital )behind the eye) mid sagittal (top of the head) occipital (back of the head), sinuses {frontal and maxillary} and the upper cervical regions (upper neck)

Patients localized facial pain to: the joint(s) , deep ear, temple, upper jaw, lower jaw.

Patients were asked how long the pain and joint dysfunction had been present before surgery:  0-6 months;  6-12 months;   1-2 years;  2-5 years;  greater than 5 years.

Patients were asked:  “If you had two or more types of headache, could you distinguish other types of headache from those associated with joint arthritis?”

Finally, patients were asked whether they were using: 1) More;  2)the same 3) less;  or 4)no medication to control headache pain after surgery.

RESULTS

The patients ranged in age from 18 to 57 with a mean of 39 years.  66 of 76 patients (89.5%) reported constant symptoms for at least 1year of   of jaw pain, chewing pain, inability to eat a normal diet, jaw joint locking, and progressive difficulty with mouth opening due to any of the above.

32 patients (42.1%) had symptoms for greater than five years {See editorial commment below).  Only 8 patients had symptoms for less than one year.

70 of 76 patients (92.1%) described constant pain, well-localized in the TM joint or pain that felt like a constant ear ache. (otalgia)Prior to surgery, 52 patients (68.4%) had constant headache  and 18 more (23.7%) reported several significant headaches per week.

There was no specific localization of reported headache that was more dominant than any other location.

32 patients in this study had disc/capsule repair arthroplasty for Wilkes II-III derangement.  44 patients had discectomy procedure because chronic inflammatory and biomechanical destruction had made repair impossible. Wilkes IV-V.   (See previous blogs for examples of this type of tissue condition compared to normal specimens). No distiction was made between these two surgical procedures as it related to long-term pain response.  No disc replacement substitutions of any type were placed in these patients.

4 years after TMJ surgery for advanced derangement, Pain and headache sympoms had improved.The following tables list the results of  the 76 patient responses:

TM Joint/Facial Pain  Frequency # Patients before surgery # Patients after surgery
Constant 70 3
Weekly (1-2  requiring medication) 6 29
Monthly 0 27
None 0 17

Headache Frequency

TM Joint/Facial Pain  Frequency # Patients before surgery # Patients after surgery
Constant 52 5
Weekly 18 23
Monthly 3 27
None 3 (all male) 21

69 patients provided responses about whether they could distinguishh types of headache.  49 respondents stated that they could distinguish headaches arising from TM joint disease/dysfunction/arthritis from other headaches, 20 could not.

The most signigicant reported result in my estimation after 4 years post operatively was that 55 of the 70 respondants (78.6%) indicated that they needed less medication or no medication to control headache after surgery and had been able to no longer require continual medical evaluation/treatment for headache “of unknown origin”.

DISCUSSION

There are many (hundreds) of potential, interconnecting biological causes for severe chronic headache….as the classification system of the International Headache Society would attest.  The National Institutes of Health estimate that 10 million Americans will have advanced TM joint disorder.  Consistent data in the literature suggests 10% of this number will have advanced jaw joint disease capable of creating significant human impairment. This web site is dedicated to presentation of concern to that population and MRI/surgical photos of that level of disease are and will be provided in this web site. (Also consult ASTMJS.org)

Most dental and medical providers are taught that “TMJ headache” is a  muscular disorder of the muscles that move the lower jaw. No one can argue that when the jaw joints are orthopedically unstable, that chronic muscular dysfunction will be part of the picture….similar to other orthopedic joint problems of the musculoskeletal system.   However, such a theory would logically suggest that headache in these patients be localized, if solely muscular, to the muscles that operate the jaw.  This was not the finding in this study as headache localization could be anywhere….as suggested by the finding that there was no predominant localization and many patients had headache which was confused with a vascular headache or migraine phenomenon. (See previous blog and discussion on severe inflammatory destruction of jaw joint “cartilage” and vasoactive substances produced and found in advanced joint derangement/arthrosis).

Anectdotes after 30 years of surgery experience.

Over 40% of my patients in this study had significant headache symptoms for over 5 years before considering surgery “as a last resort”.  Part of this is due to the age old bias among health care providers, as a group, for many reasons. For many of these patients, a physicians advice to “go see your dentist” was the recommendation when joint pathology was suspected.  Most all dutifully did and underwent numerous dental related treatments with no improvement.  Not a single patient in this group (remember, this was 18 years ago), ever had detailed imaging (MRI) of the jaw joints before being referred for treatment…or during any dental related treatment.   Sadly, today, things are not much better when extensive dental treatment is undertaken to treat “TMJ and associated chronic headache”.  Thankfully today, physicians are more apt to request imaging of their patients if they wish to rule out this condition.

Headache localization in patients with derangements that are not terribly advanced but early in their history.. but dysfunctional none the less are usually localized by them as temporal or retro orbital.  Advanced degenerative cases are associated with a generalized “cephalgia” or a headache that can be anywhere, and often diagnosed as a vascular or “migraine” type headache…See IHS website and classifications.  These are types that often require a multiple medical approach in the peri-operative period.  (Treated as muscular and vascular…see previous blog)

It all relates to a duration of signs/symptoms evaluation.  Chronic unstable joint dysfunction for greater than 1 year, non responsive to acceptable and reasonable dental related treatment, often leads to secondary chronic headache in individuals who have progressive biomechanical dysfunction of the jaw joint capable of tissue destruction.   It is important to image and treat at an early stage, to prevent needless chronic pain  and advanced joint degeneration of all sorts for becoming part of the package.

Most all epidemiologic surveys of patients show that significant pain and problems are seen in women far more than men.  A biomechanical explanation has been provided in this web site.

The following quote is is a summary statement in this paper that was consistent with this group of patients studied and continues to be true today in my clinical/practice experience….and I might suggest all who manage this health problem…see  ASTMJS.org :

“The predominance of TMJ syndrome (pain complaints) in women may be theoretically explained by experimental (neurological) data.   Bereiter, (and many others now…this was a classic paper) demonstrated that systemic estrogens increase the size of receptive fields of trigeminal nerve mechano-pain receptors.  This change occurs even after  resection of the nerve origin at the base of the brain (animal studies and after trigeminal nerve surgeries for cranial nerve neralgias that create incapacitating human facial pain)  suggesting hormonal induced  changes at peripheral regions (structures outside the central nervous system that receive their sensory input from the trigeminal nerve ).   The effects of domestic jaw trauma, hormone-induced or mediated inflammatory destruction of fibroelastic tissues of the TM joint system, osteoporosis-induced degenerative diseasee, and periodontal bone loss with posterior tooth loss may also contribute to the high incidence of this condiditon in women. ”

“Analysis of my patients who did not get well reveals principles found in other joint systems.  Patients with long-standing joint pain and destruction , never previously diagnosed carry a poorer prognosis for a satisfactory result than those diagnosed much earlier. ……Patients who have had long-standing internal derangement (greater than 2 years) and no ressponse to reasonable non-surgical/medical management (3 months) may improve but continue to have pain consistent with occasional but chronic arthralgia.  This type of patient made up the majority of those who only had a fair result by my estimation.  In my experience, patients with long-standing degenerative disease or arthrosis have pain syndromes that are difficulty to manage.”   To that, add patients who have had significant documented “vascular or migraine” headache since childhood, and may have sustained a jaw injury later in life creating a TMJ derangement…. are a particular challenge.

Finally,  a paper like this invites risk..  and that was my greatest concern when it was published after review by the editors at Duke University…risk of an uniformed, desperate patient to seek out  TMJ surgery  with the specific goal to “”cure my headaches.”  These patients have always scared me personally and anyone who works in this field…..

Never should one have any expectation of hoped for successful headache management unless they can document four fundamental and consistent issues:  one….they have had all other serious potential causes for chronic headache ruled out by a certified neurologist or other medical provider(s)…..2) that there is documentation with imaging of significant jaw joint intrinsic disease and that significant orthopedic dysfunction/well localized joint or ear ache type pain that  is not responting to:….3)  All reasonable and acceptable non surgical dental and medical management….and..4) the patient is psychologically stable, oriented, and consistent with ability to relate cause and affect….reasonable people accept there are no guarantees in our individual and collective life experiences.

Kirk, Jr. William S. :  “Chronic Temporomandibular Joint Disease and Head Pain/Response to Surgery”  North Carolina Medical Journal, January 1993, Volume 54, Number 1, PP.30-32 and 45.

Bereiter DA, Standord Lf, and Barker , DJ:  Hormone -induced enlargement of receptive fields in trigeminal mechanoreceptive neurons. II Possible mechanisms. Brain Research, 1980; 184;  411-23.

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